| NPI | 1104241595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: VA 0101258741) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2014-02-22 |
| Last Update Date | 2024-05-13 |